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Event Notification Report for December 22, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/19/2014 - 12/22/2014

** EVENT NUMBERS **


50573 50597 50669 50673 50696 50697

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50573
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: WILLIAM MUFFLEY
HQ OPS Officer: JEFF ROTTON
Notification Date: 10/29/2014
Notification Time: 13:54 [ET]
Event Date: 10/29/2014
Event Time: 07:11 [EDT]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
BRICE BICKETT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 98 Power Operation 98 Power Operation

Event Text

LOSS OF CONTROL ROOM EMERGENCY AIR CONDITIONING SYSTEM OPERABILITY

"At 0711 EDT, Salem Unit 2 entered TSAS [Technical Specification Action Statement] 3.0.3 due to the Salem Unit 1 - 1B Vital instrument bus inverter failing which resulted in a loss of the Unit 1 - 1B Vital instrument bus. The loss of power to the 1B Vital instrument bus resulted in Salem Unit 2 initiating the accident pressurized mode of control room ventilation. All dampers and fans repositioned correctly with the exception of the Unit 1 Control Room Emergency Air Conditioning System (CREACS) intake dampers, 1CAA48, 50, and 51. The 1CAA48 was pinned closed to support Unit 1 - 1A125VDC scheduled maintenance. The 1CAA50 and 51 failed to move to the open position (required for Unit 2 accident pressurized mode) due to the loss of power to the 1B Vital Instrument Bus. With the 1CAA48, 50 and 51 dampers closed, this isolated the Unit 1 CREACS intake in the closed position. For an accident in Unit 2, the CREACS intake for Unit 1 is required to open.

"Salem Unit 2 exited TSAS 3.0.3 at 0822 EDT when the 1CAA50 and 51 were pinned in the open position to implement accident pressurized mode for Salem Unit 2 in accordance with S1/S2.OP-SO.CAV-0001, Control Area Ventilation Operation.

"Salem Unit One is Defueled.

"This event is being reported under the requirements of 10 CFR 50.72(b)(3)(v)(D) as 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of systems that are needed to perform mitigation of the consequences of an accident.'

"The licensee has notified the NRC Resident Inspector. No one was injured as a result of the failure of 1B Vital instrument inverter."

The licensee notified Lower Alloways Township.

* * * RETRACTION FROM BILL MUFFLEY TO HOWIE CROUCH AT 1529 EST ON 12/22/14 * * *

"A subsequent review of the condition reported on 10/29/2014 in EN 50573 determined that the Control Room Emergency Air Conditioning System (CREACS) was operable and capable of performing its safety function. Therefore, there was no reportable condition.

"Circuit analysis identified that the Unit 2 Control Room Intake Isolation (CRIX) Train B circuit remained fully functional and able to respond to a Unit 2 Safety Injection (SI) signal or actuation from radiation monitor 2R1B Channel 1 (radiation levels in the Unit 2 normal Control Area Ventilation intake). The loss of the 1B vital instrument bus did not affect the normal actuation circuitry. The appropriate Unit 1 dampers would have received an open
signal and the appropriate Unit 2 dampers would have received a closed signal, thereby isolating the Unit 2 CREACS intake and opening the Unit 1 CREACS intake. Thus, the CREACS would have been capable of mitigating the consequences of an accident.

"The NRC Resident Inspector has been notified."

Notified R1DO (Ferdas).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 50597
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: RYAN MEREMA
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/06/2014
Notification Time: 04:30 [ET]
Event Date: 11/05/2014
Event Time: 19:38 [CST]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
DAVE PASSEHL (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

SIX UNIT 2 CONTROL ROD DRIVE HYDRAULIC CONTROL UNITS INOPERABLE

"Six (6) U2 CRD [Control Rod Drive] HCU [Hydraulic Control Unit] accumulators were identified with riser brackets that were installed incorrectly. This issue impacts U2 CRD HCU accumulators only. The incorrect riser bracket installation could challenge the ability of the CRD hydraulic control unit to perform its design function during a seismic event.

"Identified U2 control rods associated with HCU accumulators that had riser brackets installed incorrectly were declared inoperable. This condition has been corrected since initial identification, restoring all control rods to operable status. Reference IR 2407342.

"This notification is made pursuant to 10CFR 50.72(b)(3)(v) regarding the reportability of multiple failures that could have prevented fulfillment of a safety function.

"The NRC Resident Inspector will be notified."

* * * RETRACTION FROM MATT SEELEY TO HOWIE CROUCH AT 1144 EST ON 12/22/14 * * *

"The purpose of this notification is to retract the ENS notification made on November 6, 2014 (ENS 50597). An Engineering Evaluation has determined that the function of the affected U2 CRD HCU Accumulators was not affected as discussed in Chapters 6 and 15 of the Updated Final Safety Analysis Report. Therefore, the threshold for reporting the issue as an event or condition that could have prevented the fulfillment of a safety function was not met (NUREG 1022, Revision 3, Event Report Guidelines Section 3.2.7).

"The NRC Resident Inspector has been notified."

Notified R3DO (Dickson).

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Agreement State Event Number: 50669
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: KOURY GEOTECHNICAL SERVICES
Region: 4
City: CHINO State: CA
County:
License #: 6449-19
Agreement: Y
Docket:
NRC Notified By: ANDREW TAYLOR
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/11/2014
Notification Time: 13:25 [ET]
Event Date: 12/10/2014
Event Time: [PST]
Last Update Date: 12/11/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
HEATHER GEPFORD (R4DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TROXLER MOISTURE DENSITY GAUGE

The following information was obtained from the State of California via email:

"On December 10, 2014, the Assistant Radiation Safety Officer of Koury Geotechnical Services contacted the Radiologic Health Branch Brea office regarding a moisture density gauge that was run over by a construction vehicle at a construction site at 6500 Atlantic Avenue in Long Beach. The gauge was a CPN Model MC1-DRP gauge, S/N MD30901675 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was in use as the Cs-137 source was extended approximately 8 inches in the soil at the time of the incident. The source rod has been damaged. The electrical body was also damaged but there was no evidence that the protective shield or the Am:Be-241source was damaged. The Long Beach Fire Department was notified and responded to the incident. Fire Department personnel did a visual inspection and radiation survey of the area and noted that the area was secured at least 50 feet from the gauge and noted that the dose rates at this boundary were at background. Long Beach Hazmat then arrived to take control of the area from the Fire Department. After assessing the situation they contacted Los Angeles County Radiation Management to assist in placing the sources in a safe condition. Thomas Gray and Associates (California materials license number 2105) was also contacted to assist in remediating the damaged gauge. The Health Physicist from Los Angeles County, with assistance from the Thomas Gray technician, was able to place the Cs-137 source into the shielded position and verified that the shutter block was in the proper position. A visual inspection of the body was performed and indicated that there was no damage to the shielding. Wipes were taken on the body of the gauge then tested using a survey meter with a geiger-mueller pancake probe. The wipes were at background indicating that the sources were not leaking. An MCA [multi-channel analyzer] was used to verify that both the Cs-137 and AmBe-241 sources were present. The gauge body was placed in the transport case along with the rest of the gauge parts then turned over to the Koury technician to take to Maurer Technical Services (California radioactive license 6163) to be shipped to the manufacturer so that it can be repaired or the sources recycled.

"The investigation is on-going and any citations will be determined at a later date."

CA Report No.: 5010-121014

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Agreement State Event Number: 50673
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: UNIVERSITY OF MARYLAND HELEN DENT CANCER CENTER
Region: 1
City: OLNEY State: MD
County:
License #: MD-31-310-01
Agreement: Y
Docket:
NRC Notified By: RAY MANLEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 12/12/2014
Notification Time: 14:40 [ET]
Event Date: 12/10/2014
Event Time: [EST]
Last Update Date: 12/12/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1DO)
NMSS EVENTS NOTIFICA (EMAI)

Event Text

MARYLAND AGREEMENT STATE REPORT - MISADMINISTRATION OF I-125 SEEDS DURING PROSTATE THERAPY

The following information was obtained from the State of Maryland via email:

"Post implant CT determined that all seeds missed the prostate and were deposited in an unintended area of soft tissue at the base of the patient's penis. A medical determination has been made to not remove the seeds due to the difficulty of removal. The patient will be followed over the next two weeks to determine whether damage to the urethra has occurred. The licensee states that the patient has been informed.

"Preliminary root cause evaluation is that the Medical Center's ultrasound unit used to guide insertion is 12 years old and has a poor (grainy) display. No defect with the Mick applicator has been determined.

"The Maryland Radiation Program will conduct an on-site investigation of this incident."

The patient was administered 53 seeds at a nominal 0.36 mCi I-125 per seed manufactured by Best Industries. Intended dose to the prostate was 108 Gy.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 50696
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: SAM NAKAMINE
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/19/2014
Notification Time: 14:57 [ET]
Event Date: 12/19/2014
Event Time: 11:00 [EST]
Last Update Date: 12/19/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

FITNESS FOR DUTY REPORT - CONTRACT SUPERVISOR TESTED POSITIVE FOR ILLEGAL DRUGS

A contract supervisory employee had a confirmed positive test for illegal drugs during a random fitness-for-duty test. The employee's access to the plant has been terminated.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 50697
Facility: COOK
Region: 3 State: MI
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: KURT BERAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 12/20/2014
Notification Time: 13:39 [ET]
Event Date: 12/20/2014
Event Time: 12:12 [EST]
Last Update Date: 12/22/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
AARON MCCRAW (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO OIL LEAK FROM MAIN TURBINE LUBE OIL SYSTEM

"At 1212 EST on December 20, 2014, D.C. Cook notified the State of Michigan and local authorities of an oil leak from the Unit 2 Main Turbine Lube Oil Cooler to Lake Michigan. Approximately 2000 gallons have leaked into Lake Michigan since October 25, 2014. No visible oil or oil sheen is present on Lake Michigan or the shore line. The leak is currently isolated as of 1030 EST on December 20, 2014. Leak repairs will be made to the cooler prior to placing back in service.

"The NRC Resident Inspector was notified.

"This notification is being made in accordance with 10 CFR 50.72(b)(2)(xi) due to notification of offsite agencies."

Notified DOE, EPA, USDA, HHS, and FEMA.

* * * UPDATE FROM PERRY GRAHAM TO HOWIE CROUCH AT 1432 EST ON 12/22/14 * * *

The licensee issued a press release about this event this afternoon.

Notified R3DO (Dickson).

Page Last Reviewed/Updated Monday, December 29, 2014
Monday, December 29, 2014